Sterilization Practices and Protocols for The Medical Office
1. Transportation of all contaminated instruments from room to room must be carried out in
a lidded and closed container (such a stainless surgical tray).
2. Any used and contaminated tools must be placed in the tray containing water/germiphane
solution to the right side of the utility room sink for a minimum of 30 minutes to dissolve
residues before scrubbing.
3. When preparing for cleaning surgical instruments, put on gloves, a gown, goggles and
mask to minimize exposure to contaminants.
4. Fill the right sink with warm water and one capful of germiphane. In the other sink, place
the white dish drainer (without the towel beneath it).
5. While submerged underwater, use the small brush in the white soap dish to scrub any
organic material from tools. This is to limit the amount of organic matter splatter in
surrounding areas….including you.
6. After scrubbing each tool individually, put them in drainer. When you are finished
physical cleaning, inspect and rinse all the instruments.
7. Bring dish drainer of clean, but unsterile, tools over to “Clean” side of Utility Room and
place on top of a clean towel.
8. You can now remove your safety gear…..
9. Dry each tool manually, unless you leave them to air dry, and place upon clean paper
towel.
• Sort instruments into groupings of: Suture Removal – One pair of non-toothed adsen
forceps and a pair of suture scissors.
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Suture Kit – One pair of non-toothed Adsen forseps, one pair of toothed Adsen
forceps, one pair of needle drivers, one pair of sharp-nosed scissors and a small
stainless steel bowl with 2”x2” gauze.
IUD kit – tenaculum, sounder, long-handled scissors, long-handled ring forceps,
small stainless steel bowl with 2”x2” gauze
Surgical Bowl – Small stainless bowl and 2”x2” gauze.
Bandage scissors do not get packaged in a pouch; they are to be placed on trays
unpackaged.
All other instruments can be packed singularly.
10. Package each group or instrument in an appropriate-sized sterilization pouch with
handles facing downward while making an attempt to keep all hinged instruments open to
allow for steam to reach all surfaces. If a galley bowl is included in pouch, face opening
toward paper side.
11. After packaging, write your initials and stamp date on the left side of the closing flap on
each pouch. Record this in the log book in the drawer under the autoclave. If you are not
going to autoclave these items immediately, put the packages in the “NOT YET
STERILE” bin to the left of the autoclaves.
12. If sterilizing packages, please write you initials and stamp the date on the right side of
each pouch as well and record that you are autoclaving this cycle in the log book.
13. Each full sterilization pouch can be arranged on one of the four autoclave trays. Trays are
able to hold more than one pouch at a time, but an effort should be made to ensure that
each tray is not overloaded or the instruments with not reach optimal sterilization
temperature.
14. After checking to ensure that autoclave has enough distilled water in the reservoir, press
“Pouched Cycle
15. A biological spore indicator test (BI) must be included in a load weekly.
16. Record date, time, temperature, your initials, if a BI strip was included, in logbook (Kept
in the drawer under the autoclave.)
17. The cycle will complete on it’s own and the door will pop automatically.
18. After tools have cooled enough to touch, remove from autoclave and place all sterilized
packs in the clear basket on counter marked “Sterilized” to completely dry before
distributing to appropriate rooms. When replacing packs in treatmet rooms, please ensure
all of the instruments that have been sterilized most recently are put in the right side of
baskets. This allows the older tools to be used sooner and keeps them in constant rotation.
19. Clean all transportation and cleaning supplies with germiphine and hot water and replace
in their appropriate locations.
20. Autoclave must be drained and water refreshed with fresh DISTILLED water once per
week. Once per month, the autoclave must be thoroughly cleaned with Omni Clean,
dismantled and checked for flaws. Run a BI spore indicator and record results in log book
when completed.
Action
Sample Autoclave Log Book
Packaged Date and Sterilization Date
Initials
and Initials
Cycle#
P ouched
Jan 3 , 16-
Jan 3 , 16-
A
C ycle
JC
RS
2 P ouched
Jan 4 , 16-
Jan 4 , 16-
C ycles
RS
RS
W eekly
Jan 4 , 16-
M aintenance
RS
B I Spore
Jan 4 , 16-
Indicator
RS
N E G A T IV E
A & B